Get the free Reimbursement Account Enrollment Authorization forms - documents dgs ca

Clear STATE OF CALIFORNIA DEPARTMENT OF HUMAN RESOURCES R Print REIMBURSEMENT ACCOUNT ENROLLMENT AUTHORIZATION DESELECT PROGRAM STD. 701R (REV. 10/2014) Please type or use ballpoint pen and print

How to fill out reimbursement account enrollment authorization

How to fill out reimbursement account enrollment authorization:

1. Begin by obtaining the reimbursement account enrollment authorization form from your employer or insurance provider.
2. Carefully read through the instructions provided on the form to understand the required information and any supporting documents that may be needed.
3. Fill out your personal details accurately, including your full name, address, contact information, and social security number. Make sure to double-check for any errors.
4. Provide information about your employer, such as the company name, address, and contact details.
5. Indicate the type of reimbursement account you are enrolling in, whether it is a flexible spending account (FSA) or a health reimbursement arrangement (HRA).
6. Specify the enrollment period or effective date of the reimbursement account.
7. If required, indicate your desired contribution amount or percentage for the reimbursement account.
8. Sign and date the form, ensuring that you fully understand and agree to the terms and conditions stated.
9. Submit the completed reimbursement account enrollment authorization form to your employer or insurance provider as instructed, either in person or through the designated submission method.

Who needs reimbursement account enrollment authorization:

1. Employees who wish to participate in their employer's offered reimbursement account programs, such as flexible spending accounts or health reimbursement arrangements, typically need to fill out a reimbursement account enrollment authorization form.
2. Some insurance providers may also require individuals to complete this form when enrolling in their own reimbursement account programs.
3. It is important to check with your employer or insurance provider to determine whether you need to fill out the reimbursement account enrollment authorization form to take advantage of these benefit programs.

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